Presentation and Management of Laparoscopic Incisional Hernias

The incidence of incisional hernias at 12 mm trocar sites after laparoscopy has been reported as approximately 3%. We report on three cases involving this post-operative complication. The patients underwent a laparoscopically-assisted hysterectomy (LAVH) with fascial closure of 12 mm ports. Each patient presented on postoperative day number two with crampy abdominal pain, nausea and vomiting. Abdominal x-ray findings were consistent with a partial small bowel obstruction. Two patients were re-explored laparoscopically shortly after presentation. One was found to have omental herniation into the pre-peritoneal space which was easily reduced endoscopically with blunt traction. The second patient had a loop of ileum herniating through a small fascial defect. The hernia was repaired by expanding the fascial defect and then digitally replacing the ileum intraperitoneally. The third patient was managed conservatively with nasogastric tube decompression. When symptoms did not resolve completely, the patient was re-explored laparoscopically on postoperative day 21. An adherent loop of small bowel was found in the pre-peritoneal space. Due to trauma in reducing the hernia, a segmental resection of bowel was performed extracorporeally by pulling the damaged bowel through the trocar incision. No patient had complications from the repaired hernias. To avoid this postoperative complication, we now use the Grice suture needle to close both the peritoneum and fascia of all 12-mm trocar incisions. In managing trocar incisional hernias we found that early laparoscopic evaluation allowed both diagnosis and expedient treatment of the patient. Conservative management resulted in a more adherent herniation which was less amenable to easy repair